This is a blog by a former CEO of a large Boston hospital to share thoughts about hospitals, medicine, and health care issues.

Friday, April 09, 2010

Hospitable hospitalists

I was invited to give the keynote address at the national meeting of the Society of Hospital Medicine in Washington, DC. SHM is committed to enhancing the practice of hospital medicine by promoting education, research and advocacy and has more than 10,000 hospitalist members. They asked me to speak on "The hospitalist's role in the hospital of the future." (Here's a story they wrote afterward.)

Who should I run into but our own Chief of Medicine, Mark Zeidel, who had been invited to be the featured visiting professor for the conference, providing mentoring and insight to those in attendance. You see Mark here with Scott Flanders, Director of the Hospitalist Program at the University of Michigan Health System and President of the SHM.

Hospitalists are now the largest specialty group in medicine in the country, with approximately 28,000 in the profession overall. As noted by panelist Ronald Greeno (on the right), they have a key role to play in improving quality and reducing waste in the hospital environment. He was joined in those sentiments by Patrick Conway and Leslie Norwalk, who further expanded on the implications of the recently passed health care reform act.

About 2,500 people attended this session, including strong representation from BIDMC and several alumni of our program who currently work at other hospitals in the country. Joe Li, one of the first hospitalists in Boston, was voted to be President-elect of the Society and will serve as President next year. Joe has had leadership roles regionally and has also served as the Treasurer of SHM. Congratulations for this well deserved honor!

This results in better patient care. The hospitalists are on duty all day in the hospital. The PCPs could only drop by early in the morning and at night because they have appointments in their offices all day long. Also, the hospitalists are more attuned to hospital procedures and personnel. There are other reasons, too, which others may want to expand upon.

I agree with the concept of hospitalists and Paul's comments, but the handoff of information involved,like other handoffs, has significant deficiencies. When my mother was hospitalized several months ago, I was the one the hospitalist came to for the medical history, presenting complaint and pertinent medications. (She did have a primary but he was out of town and his office seemed unable to provide much info). While I was mostly able to provide this info partially because I am an M.D., woe betide those who have no knowledgeable advocates. I am sure it frustrates the hospitalists too. This is yet another aspect of modern medicine that needs fixing.Perhaps any hospitalists reading can comment on how they overcome this obstacle. Perhaps HIT is the eventual answer, but it can't come soon enough.....

Also, many patients (particularly in urban centers like Boston) simply do not have a PCP. The Hospitalist serves as the PCP during the patient's inpatient admission and often tries to connect them with an actual PCP for life after discharge.

So, I wonder if this aspect will go away when America gets back to the "medical home" concept, where everyone does have a regular physician.

Paul,

I agree with nonlocal's point. I don't know if I ever told you, but when I was in for my nephrectomy, the people who treated me had no idea that I couldn't stand without a walker due to my bone met. (Oh, and they forgot to remove my Foley on the specified day. But that may not have anything to do with a handoff to/from a hospitalist.)

Because trying to juggle taking care of people in the hospital while seeing a ton of clinic patients is a giant pain. The government has basically pushed for this by continually cutting office reimbursements so that more people have to be seen in clinic to make the same money. The result is the increasing loss of "fringe benefits" that doctors used to do out of a sense of professional duty, like covering your hospital patients.

Hospitals are also huge fans of it because they control the hospitalists and can make them comply with any cost-saving or "standardized care" measures they like. In contrast, they have no leverage over independent PCPs and in fact those doctors have the leverage because they can just admit somewhere else. As in most things in life, follow the money.

While under a hospitalist's care, is there any communication on a daily basis with a patient's PCP or specialists they may see regularly? Is there an attempt to obtain a history?Also, a patient could feel very alone and uneasy if their regular doctors were nowhere to be found and they had no say in the matter... or do they?

I am not sure of your background but au contraire in my former hospital. There the clinicians were suspicious of the hospital's plan for hospitalists, and the initial agreement was that the hospitalists would only take ER patients with no assigned primary doc (usually these were uninsured patients whom no one wanted to cover). I don't think the primaries were covering due to "professional duty"; they were getting paid to cover their hospital patients.

Also, as Paul notes and if you read Robert Wachter's blog, hospitalists are often the ones to drive patient safety issues and standardization of patient care processes, because they are the ones directly affected by bad practice in those arenas. Yes, there is the potential for self-serving controls attempted by the hospitals, but no more so than with other hospital-based docs such as pathologists/radiologists/anesthesia/ER.

That said, I do worry about the handoff issues, but have not seen this from the hospitalists' point of view yet. Dave's story is rather compelling, duh. Perhaps Paul can enquire among his new friends. (:

At the BIDMC, our hospitalists reach out to the patient’s primary care provider (PCP) at the time of admission, after any significant events during the hospitalization, and at the time of discharge. Since we are fortunate to have an online medical record for many of our patients, outpatient records are already often available to the inpatient team. When the records are not available, the PCP is asked to fax the patient’s records to the hospitalist. If the PCP wishes to discuss the care of the patient at any time during or after the hospitalization, they can reach the hospitalist via email or page, 24/7.

It is true that a patient’s PCP can offer a reassuring, familiar presence during hospitalization. We welcome PCPs to assist in the care of their inpatients. Some PCPs visit their patients in the hospital. Sometimes, PCPs will call the patient on the telephone to speak with them and offer their support.

Practicing in a 6 person primary care group in San Diego for decades, I have a perspective on this. We continue to take care of all our hospital patients(at one hospital only), even those who are in managed care plans. We have consistently had better utilization for senior patients and have had higher patient satisfaction scores. No question, we are "dinosaurs". None-the-less, specialists appreciate personally interacting with primary care physicians in the hospital setting, as do we. It is very common for them to say, "this is how it should be". It definitely is harder to do - many more calls from nurses and from ERs. Yet, because of the personal familiarity, we sometimes are able to avoid unnecessary admissions due to the personal trust that we will see the patient quickly in our office across the street from the hospital. Hospital care is a great component of primary care training; it should not be given up in practice.

"I don't know about other places, but we don't "control" the hospitalists in the way you say. They are the ones who drive clinical protocols in our hospital, not administration."

Well, I do know for sure that that's not the case everywhere. But if you want a more neutral phrasing, one could say "the interests of the hospital and hospitalist are aligned in a way that the interests of a PCP and hospital are not, and hospitals like that". The PCP does not care all that much if the patient's LOS is longer than the insurance wants to pay for.

"I don't think the primaries were covering due to "professional duty"; they were getting paid to cover their hospital patients."

True, but at least around these parts the $$$/hassle return for taking care of hospitalized patients does not seem to be worth it for the PCPs on a purely economic basis. That's a lot of "patient urgently needs you to drive over to the hospital in the middle of clinic" and "it's 2am and patient is anuric" for a not huge revenue stream. Twenty years ago when people had smaller patient numbers in their practice and weren't seeing 30 people a day it was more doable. At least that's what I've heard from them.

For us, it is professionalism and idealism. It is intellectually stimulating and socially enjoyable to share patients with our colleagues. We are also happy that we are paid reasonably for doing so. We enjoy participating in hospital medical staff governance and feel that we bring valuable perspectives to our colleagues. We also understand their stresses well. This is why we wanted to become physicians. It also enabled us to train the next generation of family physicians until our hospital system ended its commitment to graduate medical education.